CARPAL TUNNEL SYNDROME

It seems that when anyone has pain in the wrist or hand, they immediately cry "carpal tunnel syndrome". First lets discuss true carpal tunnel syndrome, then we'll talk about other causes of wrist pain, and finally a solution from the perspective of massage.

True carpal tunnel syndrome
True carpal tunnel syndrome is characterized by median nerve entrapment, which causes pain, weakness or tingling in all fingers excluding the little finger, and only half of the ring finger.

The reason that the median nerve becomes entrapped is because the finger flexor tendons swell, decreasing the space that the nerve has to go through. The standard medical treatment is to immobilize the wrist using some kind of support, hoping the tendons will return to their normal size. The next option is to perform surgery where the transverse carpal ligament is cut, and left that way. This is designed to open space in the carpal tunnel and stop impinging on the nerve.

OTHER CAUSES: There are many causes of wrist pain that are not carpal tunnel syndrome. The tendons of the two flexor digitorum muscles may be inflamed, creating pain, without pinching the nerve. Also the ligaments in the wrist might be injured, causing pain. The forearm muscle might be tight and inflamed, referring pain down into the hand. Further up the line the pectoralis minor might be pinching nerves in the shoulder that go down into the hand (see pectoralis minor syndrome). Even higher up, the scalene muscle in the neck can also impinge on these same nerves, causing pain in the wrist and hand.

EVALUATION: A good massage therapist should be able to clearly distinguish the different pain patterns and be able to assess what is going on. Passive range of motion tests are used to test the ligaments, while active resisted tests are designed to test the muscle tendon unit. To tell if the pectoralis minor is inflamed, check to see if the muscle is tight, and perform the test discussed in the pectoralis minor article to discover if the muscle is impinging on any arteries or nerves. The scalene tests are similar- check for tightness, restricted range of motion and for any nerve impingement.

ROOT CAUSE: In my experience, the most common cause of wrist and hand pain is prolonged tension in the flexor muscles of the forearm. Even when people have true carpal tunnel syndrome, I ask myself -why are the tendons tight in the first place? The standard answer is that repetitive motion causes the tension, but it seems to me that our bodies were designed to perform repetitive motion. The real cause is the mounting tension that doesn't let up. People should be able to perform repetitive motion, and then heal at night. If the muscles are always tight, and never get a chance to relax, then they will never heal. Massage can release the muscular tension which will take the pressure off the tendons. Once the tendons get some rest, the inflammation will be reduced and they will shrink, giving the nerve more room.

MASSAGE: Because the root cause is usually muscular, massage can help tremendously. In just a few sessions most pain can be significantly reduced. Remember to work both the flexors and the extensors, and include the brachioradialis. At the end of the session all the muscle groups should be of equal tone- relaxed. You must know your anatomy to be able to accurately release the two flexor digitorum muscles. When working with people with acute pain, be sensitive to the tissue, too much stimulation will cause increased inflammation. Use ice after the session to help cool the area down.

For more information on how to tell the difference between ligament, tendon and muscle pain, pectoralis minor entrapment and other conditions, consult the video Deep Tissue and Neuromuscular Therapy, The Extremities.